Patient Questions: Probiotics, Emotional Trauma, and More - Dr. Michael Ruscio, DNM, DC

Patient Questions: Probiotics, Emotional Trauma, and More

Including: How One Symptom Led to a Mold Illness Diagnosis with Dr. Joe Mather

The first installment of our monthly patient support call covers a lot of ground. We discuss:

  1. The use of probiotics vs. yogurt for treating SIBO
  2. Addressing emotional trauma to help patients find relief from physical symptoms
  3. Time frames for using antimicrobials to improve gut health
  4. Constipation as a symptom, and the role of antimicrobials in addition to diet and other approaches 
  5. A case study describing how a single symptom led to a diagnosis of mold illness in a 73-year-old man (and a motorcycle chase!)

Questions from patients allow us to showcase the clinic’s research arm, put progressively more resources into making sure that our diagnostic and treatment process is sound, and ensure that science is thoroughly integrated into our clinical model.  

Join us every second Friday with your questions, or just listen in.

In This Episode

Episode Intro … 00:00:45
1st Question: Positive Breath Test & Yogurt as a Probiotic … 00:14:41
2nd Question: Healing Symptoms & Emotional Work … 00:19:39
3rd Question: Gut Symptom Healing Time & Antimicrobials … 00:32:35
4th Question: Antimicrobials & Bowel Movements … 00:39:15
Case Study: Constipation, Eczema, and Suicidal Thoughts … 00:44:24
Episode Wrap-Up … 00:50:24

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Hey everyone. Today I spoke with Dr. Joe Mather, the medical director at our clinic. There were a number of questions that came up during our last patient support call that we thought would be helpful to cover here so as to benefit everyone. One of the questions we covered was – Is it possible to heal symptoms completely without doing emotional work? We also discussed – How long does it typically take to see improvements in gut symptoms when using antimicrobials? Additionally, the question of – After having a positive breath test for SIBO, should I take probiotics and/or use unsweetened yogurt? We covered a case study wherein we were able to resolve mold exposure illness quite easily, but we really showcase a few important facets of how to navigate the mold picture.

We also interwove our progressive commitment to research and how that is actually enabling us to practice better healthcare, the interplay between research and science, and the constant evolution of our clinical model. Just a quick reminder — if you or someone you know is in need of help, please feel free to use the clinic as a resource and feel free to refer patients over to us. We are more than happy to help however we can. And thankfully, now that we have a team of excellent clinicians, there is no longer a wait to be seen as there was when it was just me. There could have been a 3, 4, 5, 6, 7 month wait to be seen, depending on how busy I was. I’m really happy that we can now offer what I feel to be excellent clinical care in a much more timely fashion. Okay, here we go to the conversation now with Joe.

➕ Full Podcast Transcript

Episode Intro:

Welcome to Dr. Ruscio Radio, providing practical and science-based solutions to feeling your best. To stay up to date on the latest topics, as well as all of our prior episodes, make sure to subscribe in your podcast player. For weekly updates, visit DrRuscio.com. The following discussion is for educational purposes only and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking with your doctor. Now, let’s head to the show.

Dr. Michael Ruscio:

Hey everyone. Today I spoke with Dr. Joe Mather, the medical director at our clinic. There were a number of questions that came up during our last patient support call that we thought would be helpful to cover here so as to benefit everyone. One of the questions we covered was – Is it possible to heal symptoms completely without doing emotional work? We also discussed – How long does it typically take to see improvements in gut symptoms when using antimicrobials? Additionally, the question of – After having a positive breath test for SIBO, should I take probiotics and/or use unsweetened yogurt? We covered a case study wherein we were able to resolve mold exposure illness quite easily, but we really showcase a few important facets of how to navigate the mold picture. We also interwove our progressive commitment to research and how that is actually enabling us to practice better healthcare, the interplay between research and science, and the constant evolution of our clinical model. Just a quick reminder — if you or someone you know is in need of help, please feel free to use the clinic as a resource and feel free to refer patients over to us. We are more than happy to help however we can. And thankfully, now that we have a team of excellent clinicians, there is no longer a wait to be seen as there was when it was just me. There could have been a 3, 4, 5, 6, 7 month wait to be seen, depending on how busy I was. I’m really happy that we can now offer what I feel to be excellent clinical care in a much more timely fashion. Okay, here we go to the conversation now with Joe.

DrMR:

Hey everyone. Welcome back to Dr. Ruscio Radio. This is Dr. Ruscio here with Dr. Joe Mather, our Director of Clinic Operations at the clinic, and progressively becoming a hive mind partner. I think we’re getting to the point now, Joe, where I can just think something and you hear it somehow through this connection that we have. Glad to be back on the podcast with you here to discuss clinical insights and hopefully give people some pointers to help them along their healthcare journeys.

Dr. Joe Mather:

Happy to be here. Before we started working together and becoming close friends, I had the advantage of hearing you whisper into my ear from the podcast for years and years. And I’m sure there are lots of clinicians and practitioners who feel like they know you to a degree just simply because they’ve heard so many of your thoughts and opinions.

DrMR:

It is funny how that works when you’ve been listening to someone for a while. You feel like you know them already. It’s definitely great to see. We have a growing clinical team of people who seem to be in that same sort of boat with Rob and Gavin and Hannah. That’s a good jumping off point for just a few updates regarding what we’re doing at the clinic. This is probably somewhat apparent, but we do have dedicated personnel at the clinic for research purposes — meaning (partly or exclusively) their job is to go into the research literature and codify a research brief in order of best quality down through poorest quality and information, supporting and contradicting a given point. And this has been hugely helpful because now we can put even more resources into (as we’ll come to later, just to put a little foreshadow) how much of a problem is Blastocystis hominis, as one example. These research briefs help us stay increasingly abreast of what the science is saying.

DrMR:

This is even more important when we consider that we’re really doing an examination of what the overall body of evidence says. As I’m sure people listening to this have become accustomed to us criticizing — If you’re super jazzed about X, you can cherry pick studies finding more “support” for X. But if that support represents 5% of the published science and 95% of the published science contradicts X, then you’re really functioning as someone who’s dogmatic or a zealot. What we’re doing is really able to look at, in a progressively accurate fashion, an entire body of literature, get a sense for the direction of the finding, and how we can incorporate that into our clinical model. It’s exciting to see enhancements both in research and in clinical practice. And these two things really do hold hands with each other.

DrJM:

As a medical director, I don’t know of any other clinic that is actively building a research arm that informs clinical decisions. And it’s so exciting to see the result of that because in a real time basis, we can update how we treat patients with the best evidence. And there is so much medical information coming out every single day – evidence on both sides of any issue – that if you don’t have a dedicated arm in this day and age, you are very quickly going to fall behind. I’m so proud to work at your side doing this because it’s not every clinic that gets the advantage of a research team. We’re really lucky in that regard.

DrMR:

You also say it really well in the sense that there’s just so much literature being published. Now, it’s really taking a team of us to keep pace with it. As I mentioned before, I was doing this for an hour every night, but as I started growing, it wasn’t just an hour a night. It was an hour a night plus maybe three to five hours in a week organizing the data, thinking through it, and then trying to disseminate it and/or weave it into the clinical model. It wasn’t sustainable. If I’m being honest, there were years there where I was just working an untenable number of hours. We all have to do that in the short term for getting to the next level, but it definitely wasn’t tenable.

DrMR:

So, even more reason why I’m glad we have a team of us who are working together on not only the research, but also something that you and I have been working a lot on lately. It’s how do we better describe what we’re doing at the clinic to individuals? And we’ve been using this moniker of our model is this diet, lifestyle, and gut health foundations model. It’s the foundation that we start with. This clinical structure is guided by biostatistics and it’s personalized to the individual. An example (that we’ve mentioned many a time, but I think is just worth constantly echoing) is hypothyroidism at a more generous range of the estimate affects 1% of individuals… IBS affects 10% to 15% of individuals. So right there, you can clearly see an example of when in doubt regarding where symptoms come from, you have a 10% to 15% higher probability that those symptoms are coming from the gut.

DrMR:

We will start there. We’re not going to ignore thyroid, but we’re going to have an order of operations. This diet, lifestyle, and gut health foundations model informs how we think and how we work a patient up. So, we make sure we’re not jumping right to the 1%. The other thing that we’ve been tying into this messaging is patients may come in very much convinced the problem is coming from their thyroid. And again, we are open, but another unfortunate contributing factor to why some patients are chasing the 1% instead of the 15% (thyroid versus gut) is because of the way the Google algorithm (or search algorithms) work. The more people find a hypothesis enticing and read about it, the more Google will reward those articles. It’s very likely that there’s just something appealing about thyroid being the cause of your problems. People have maybe an easier time associating this than a gut disorder or imbalance driving (let’s say) depression, fatigue, and dry skin. And the more people read about thyroid as the cause, the more when they search “causes of my fatigue,” they will get articles on thyroid. It’s incumbent upon the clinician, obviously, to help reconcile some of those disparities. Joe – I know I’m probably preaching to the choir here, but let me pause for a moment if you have anything you wanna piggyback on that.

DrJM:

What you’re saying is, with the advent of Google and social media, we get access to a lot more information. But the information that we plug into Google may not be the most accurate clinical model because the narratives that are awarded are the things that are talked about the most – not necessarily the things that are most clinically efficacious. In the thyroid world, we hear article and article and article on food sensitivities driving thyroid and you hear very little on optimizing gut. However, from a clinical perspective, we see all the time that when you optimize the gut, start patients on the proper diet with probiotics, some fasting, or an elemental diet, we see those TPO antibodies drop in case after case. And it doesn’t require meticulous testing for food sensitivities. But then again, maybe one out of three patients who come in with Hashimoto’s really has this ingrained, almost religious, belief that it has to be identifying the two or three most common food allergens to get better and they’re frustrated as to why they are not better.

DrMR:

That’s a great point. There was a study that we discussed on the podcast. They took 60 patients who still had fatigue and instability of their TSH while on Levothyroxine. 30 of them were given a placebo. The other 30 were given probiotics. Only in the probiotic group did the researchers document improved fatigue, stabilized TSH, and a lower dose of Levothyroxine was required, but you don’t hear a lot of that being championed for some reason. People tend to go down the gene rabbit hole or whatever. So, we’re getting down the rabbit hole here, but the one take home I’d want people to have is don’t be too tightly tied to a hypothesis that you form from doing Google research. That’s a good starting point. But if you trust the clinicians you’re working with, trust that they’re looking at this more from a raw data perspective – meaning what’s coming through the published research stream – and not so much so through the blogosphere or podcast or what have you because that’s where you can get some of this skewed read.

DrJM:

The blogosphere and conversations in the natural medicine world are great to generate hypotheses. And they’re really important to think of new ideas on how to treat patients, but we just have to take some of those preclinical ideas with a grain of salt until we see some clinical response in patients and evidence based to support it. What we try to do is refocus our patients on those treatments that have been proven to help rather than a theory or mechanistic idea. And there is so often in almost every single case, there is just low hanging fruit that hasn’t been properly done in a patient. Another good example of this is in Alzheimer’s disease. We have excellent, excellent trial data showing that fixing sleep apnea improves cognition. It improves short-term memory, improves cognition, and improves fatigue. You have to start there as opposed to simply bombing a patient with high doses of fish oil and vitamin E and vitamin A, which has much less evidence. There’s a first principle there. And it’s just important to take some of the recommendations with a grain of salt that you read about.

DrMR:

100%. While we’re on the topic of guiding patients, we had our first monthly support call for patients. This was a few weeks ago. It was, in my opinion, a huge success. I think we had 50-60 people there on the call. The patients who are working with any of the providers at our office had a chance just to get in a line, share their concerns, their questions, get feedback. And I think it was quite a helpful exercise because people are going to have similar questions and you learn even from someone else asking questions, almost like being in a college class. If your classmate asks an insightful question, you go, “Oh yeah, I never really thought about that.” And it helps you learn. There was a few that you picked out Joe, that you wanted to cover. Why don’t we share a few of those that we found more compelling because I think it’ll help our audience at large.

1st Question: Positive Breath Test & Yogurt as a Probiotic

DrJM:

This is a combination of some questions that we got in that session, which was so much fun and just frequently asked questions that we get in the clinic. I’ll throw these at you, Michael. And then maybe we can have a back and forth, if that’s appropriate. The first one, and this is something that we hear probably every clinic day is: I have a positive breath test. Should I take yogurt as a probiotic?

DrMR:

There seems to be two camps of thought on this use of probiotics for SIBO. And I do feel like the tide here is starting to turn where I’m seeing more providers start to figure out that the overwhelming consensus in their research literature is that yes, you should take probiotics if you have SIBO. There have been at this point, over 22 randomized clinical trials that have found that probiotics can eradicate SIBO and they clock in with an overall resolution rate very similar to rifaximin. There is no need to be cautious with or avoidant of probiotics if you have SIBO. In fact, it’s one of the mainstays of our SIBO treatment. Now with yogurt specifically — if you are dairy intolerant, then maybe not. But another feather in the cap for the utility of probiotics is the fact that probiotics have been shown in multiple clinical trials (so much so that this has even been summarized in a meta-analysis) to help people with lactose intolerance regain their ability to digest and tolerate dairy. Probiotics in this case may have a twofold benefit. They may be able to resolve the SIBO, and as they heal your gut and that portion of your gut lining that makes the lactase enzyme is repaired, you’re able to secrete more lactase, digest the lactose, and have better dairy tolerance. So, yes – probiotics are a great idea for SIBO.

DrJM:

Let me push back just slightly. I think there’s no disagreement that our approach for high dose, diverse classes of probiotics is extremely helpful for SIBO in a mainstay. But the question I’m curious to hear from you — Have you ever seen yogurt and fermented foods be enough?

DrMR:

Great follow-up on this. I think you and I are both in agreement that it’s a good dietary mainstay to have fermented foods in the diet, but they probably won’t be sufficient to eradicate SIBO. We did write an article on this (maybe six months to a year ago) where we did a direct comparison side by side for probiotics vs. common fermented food like yogurt, kimchi, and sauerkraut. Roughly one serving of a probiotic food is usually about 1/4 of one capsule of a probiotic, and oftentimes a dose for a probiotic is two to three capsules. So, you’ll get some probiotics in the foods, but it’s going to be quite a lower dose than what you’d get in a probiotic.

DrJM:

Clinically, I can’t think of a single case where someone came in, they started eating some fermented foods and yogurt and were sufficiently better.

DrMR:

This is a case study you published a little while back, Joe. It was a great case study wherein there was this uncertainty whether it was actually a SIBO relapse or if it was someone who was histamine intolerant. In the clinic, we have a subset of people who are eating a paleo diet and/or a lower carb diet and that tends to inadvertently be higher in histamine – namely higher in a lot of fermented foods. So for some people, avoiding fermented foods, at least in the short term, can actually be quite helpful.

DrJM:

Totally agree.

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2nd Question: Healing Symptoms & Emotional Work

DrJM:

Alright. Question number two. I’m actually going to go out of order here just to keep you on your toes because I think this might be a little bit more interesting. The question is: Is it possible to heal symptoms completely without doing emotional work?

DrMR:

Maybe you want to answer this one? I know you’ve had some experience in this realm that I think would be compelling to share. So, why don’t you lead us?

DrJM:

inYou’re flipping it back on me, huh? I’m doing the questions here. I think that there are patients who will not heal unless they address the emotional side or the limbic dysfunction. And as Dr. Nathan calls it – “an emotional block to healing.” Those patients very clearly exist. Let me just describe what limbic dysfunction means. That means that patients who have been chronically ill for a period of time (and particularly when they’ve been made sick by biotoxin illness like mold) the self-defense system in the brain becomes overheated and overactive. So the analogy I use with patients is instead of the mall cop just trying to scan them all and seeing if everything’s fine, you get Navy Seal Team Six and they’re machine gunning everyone down.

DrJM:

So you start reacting to the charcoal or the probiotics or really benign natural substances. That’s a big hint to me that there’s some limbic dysfunction at play. Many of those patients won’t heal unless you address the limbic piece right off the bat. But there are a lot of patients who have a background of some minor trauma, some minor disruptions in their life, and some minor emotional problems who do just fine without addressing those things. And I think the key here is really following those patients and just making sure their symptoms are going down on a regular basis. If you’re doing all of the appropriate evidence-based, practical treatments and they’re not responding, then this is one of those big flags you need to look at in your patients. I find that if I just simply tell them that and say, “Hey, Michael. I think that you’re going to get much, much better when we do X, Y, and Z. But if we’re still struggling, we’re going to circle back and maybe think about getting you into a therapist or doing perhaps The Gupta Program or some other work.” That’s the general approach I take.

DrJM:

Do you have any thoughts there?

DrMR:

No, I don’t. Very well said and fully agree. A few things to tack on in support of that. This is something that Danielle and I discussed. She was one of our patient conversation videos. She remarked that I was quite patient with my recommendation for limbic retraining. She didn’t want to do it at first. And so I said (like you were saying, Joe) – “We’ll come back to it if things don’t start clearing up.” And then things weren’t clearing up, so we came back to it, but she still wasn’t ready. And that’s where I think bedside manner and/or some of the art of clinical practice really matters — really reading the individual… seeing what’s resonating. Sometimes you have to pivot and just wait until the patient is fully ready and/or try explaining things a few different ways until they fully are able to digest it and have some resonance with it.

DrMR:

Sometimes as a clinician, you see someone would really benefit from something, but they’re not quite ready. You have to be a little bit patient and find ways to support them as best you can until they are. Also, within this patient population, framing is so incredibly important. Joe – I know you and I, and everyone at the clinic, is really very cognizant of framing. The way we frame something when someone says, “What do you think is wrong with me?”… the way we describe that is so crucially important. And without going too far left field, but we learn so much as clinicians about all of the mechanistic underpinnings of symptoms and disease — zonulin, leaky gut, toll- like receptor up regulation, pattern recognition receptor up regulation, dysbiosis, SIBO, methane, autoimmunity to the motility apparatus, gut-brain connection, limbic skewing, amygdala overactivation.

DrMR:

If you weren’t careful and you shared all those little ticks with someone, they could walk away thinking there was a whole heck of a lot wrong with them. But as a clinician, you understand that those are just things underneath the surface that (at least the way I look at this) don’t mean that there’s something wrong with you. It’s just your system is in an inappropriate environment. There’s almost this environmental mismatch, and we need to change the environment to be one befitting for you and your genes. It’s not that we need to test your genes, but we all have these paleolithic genes in a more modern/neolithic environment. Even though all this stuff happens, I look at this as there’s nothing really wrong with you — there is just this environmental mismatch. If we can find and create the environment that’s right for you, everything will go away and you will be just fine.

DrJM:

What are your favorite add-ons to change that environment for someone who might not be up for doing emotional work? Or limbic work?

DrMR:

Sure. Foundationally, it would be finding the right diet for them, improving sleep and other lifestyle measures, and gut health support. And thank you for pulling me back from my monologue, Joe.

DrJM:

That’s what I’m here for.

DrMR:

Coming back to the emotional piece, some people don’t want to do limbic retraining, and so we’ve been experimenting with this device called the Apollo Neuro. It’s a wearable that maybe will offer similar benefits to limbic retraining. And we’ve also been experimenting with what we term “ancestral stressors,” which is cold exposure… Wim Hof breathing. We usually have people read one or two books: “What Doesn’t Kill Us,” which is a book written about Wim Hof by Scott Carney who’s been on the podcast. And those together seem to give people — the ancestral stressors with corresponding reading — some empowerment and get them out of this sick care symptom/obsession framework. It helps them rediscover how strong and resilient they can be and rekindle that. And then the Apollo Neuro is this wearable that coaxes your nervous system into a more parasympathetic response through this gentle vibration that it produces on your wrist or on your ankle.

DrJM:

Absolutely. And to restate what you said — their body and mind are sometimes more convinced that they’re sick than is born by reality. And so our job occasionally is to encourage them to add as much positive stimuli to their systems or environment to outweigh that. Different patients will need different amounts. Absolutely 100% on with you with the Wim Hof breathing… the Apollo Neuro… those have absolutely been helpful for patients. And two additional things just came to mind as you were talking that I found recently really helpful. One is just strength training. It’s just challenging your patients to put muscle on. Share with them – “Hey, look, I’m going to see you in a month. I want you to have one to two pounds more muscle on your body.” And what happens is when patients start physically challenging themselves and their system, they realize that maybe they’re more well than they originally thought.

DrJM:

And the second is somewhat counterintuitive, but it is the idea that it’s very, very, very difficult to convince yourself you’re well when you’re taking 20 different supplements a day. If you are taking supplements in the morning, in the evening, before meals, and with medications, you are repeatedly giving yourself the idea that you need these treatments to be well; that you’re so sick that you need all of this stuff. It’s very freeing to have patients sometimes stop everything and see where they end up. I frequently do this exercise multiple times a week with patients and I find it really helpful. And absolutely as patients heal, we should be encouraging them to get off unnecessary treatments and try off of things. A lot of times what they needed initially to get them over an initial hump are no longer needed in the medium or long-term. Those are two more points that I think are worth trying out.

DrMR:

Very well said. And that’s part of the reason why we have patients try to really curtail off of supplements as they start care with us and wean down only to the things that they’ve noticed a benefit from. We also simplify the dosing schedule. Joe, you and I, and all the clinicians at the office – every once in a while, we’ll toss around in one of our WhatsApp groups that someone came in and we share a screenshot of the dosing protocol from their previous provider: “Wake up in the morning. Before you brush your teeth, take this. Brush your teeth, have a glass of water, take that. Wait 15 minutes and take that. Do half a walk around the block, do this. Hang upside down, take that…” I mean, I’m being a little bit facetious, but to see 11 points of dosing in a day has not been an overstatement at all. I never really actually thought about this, Joe, but I think you said such a powerful thing in that there’s a psychological aspect where it probably really entrenches this learned supplement dependence.

DrJM:

I actually kept and copied the screen from the intake for our clinic, and it’s how many supplements they’re on. And this was a moderate case of over supplementation, but they were taking 55 capsules of supplements a day. It’s just unreal the extent to which the supplement industry has really brainwashed people, and I guess that’s probably pretty fair. People can write angry emails if they disagree. L-theanine, Magnesium glycinate, Mega IgG2000, NAC two times/day. The other one was four times/day. Berberine two times/day, vitamin D, L glutathione 700 two times/day, Myo-inositol, GTA-Forte, Betaine, two to six with meals, Butyrate three times/day with meals, FODMAPs, sometimes Calcium-D-glucarate, sometimes activated charcoal, three to four caps per week… and it’s just on and on and on and on and on. And patients occasionally just need to be told to stop everything.

DrMR:

I think this is one of the most beneficial exercises that we go through — this stepwise iterative care where we’re only starting a couple things at once, so we can get a read on “Did this help you?” And if things don’t produce an impact, we’re able to say, “Okay, we’ve given this supplement it’s due trial.” And if it’s not supporting you, we’re going to stop that and do something else. Or conversely, if it is helping you, we’ve qualified that it actually does. And that’s how we prevent these huge pluming supplement protocols.

DrJM:

And happily typically save our patients a couple hundred dollars a month on unnecessary things that aren’t helping them. It goes in the bucket of really trying to keep the cost of care reasonable.

3rd Question: Gut Healing Improvement Time & Antimicrobials

DrMR:

This is a good segue into one of our other questions, which was: How long does it typically take to see improvements in gut symptoms with antimicrobials? I answered this one on the call, Joe. Maybe to be fair, I’ll hand it over to you to answer if you feel comfortable.

DrJM:

Yeah, absolutely. Generally we see a couple different patterns here. There are maybe 1/3 of patients who generally respond quickly within two weeks. That’s generally a really good sign that they’re going to get more benefit as they continue on with therapy. We’re typically treating patients for eight weeks with herbal antimicrobials. Some patients will do four weeks if they have maybe a mild dysbiosis, but generally most of our patients who deserve and need herbals we’ll do for eight weeks. So maybe 1/3 of patients respond very well fairly quickly within two weeks. There is another group of patients who tend to respond a little bit later and they may have more dysbiosis, SIBO, or infections that need to be cleared up. We generally see these patients turn around about the six week mark, which is why we generally treat for eight.

DrJM:

That’s perhaps just a function of them needing more infection to be cleared out. And then the final 1/3 of patients may not actually feel that great while on the herbal antimicrobials, but as the treatments are withdrawn, they feel excellent and amazing. And the thinking behind this is that it’s very likely the oregano is causing some mild gastritis or some of the herbs are mildly irritating to the gut mucosa. And when the rounds of treatment are completed and the patient stops it, we have both the SIBO or dysbiosis has been cleaned up – they feel better – and then the irritation from the herb is removed, as well and they start feeling better. This is typically why we have a follow-up after one week after the herbs have stopped. Those are the three buckets of when patients improve.

DrJM:

The only other answer to this question would be just recognizing that some patients will react and that does give you important information. And some patients feel worse. And that is again, important information, because if a patient is generally feeling worse on a therapy, that more often than not is an indicator that this might not be the right treatment for that patient. We would want to go back to the drawing board or try a different strategy. Those are my thoughts on the subject. Anything you’d clarify or change?

DrMR:

No. Love it. In the center of the bullseye in my opinion (and especially important just to quickly echo for people), you should have a time limitation for a Herxheimer reaction or an adjustment reaction. I think these are far more rare than many clinicians will portray them to be. And I don’t think I really ever see them or have ever seen them last beyond about a week. And I just mention that because some people will come in and they’ve been suffering with symptoms for months and thinking at some point the clouds are going to part and the onion is going to peel, and I must be doing a whole lot of good by suffering through this. I think that’s the wrong expectation — maybe a few days, maybe a week of some discomfort, but usually the pivot point is around a week. And if you’re not seeing things (in terms of negative reactions) abate at that point in time, then we should look at that as, “Okay, this isn’t right for you and let’s change up what we’re doing.”

DrJM:

Yeah. I would probably even tighten it up a little bit. I think that the cases of true die-off I see will clear up by the four day mark in my experience. If they’re still really feeling awful after a week, then that’s a pretty clear signal that it’s not true.

DrJM:

Let’s talk about nocebo though, for a minute, Michael. When I first started my practice, I thought that the die-off and Herxheimer thing was a lot more common than it actually is. And I would talk to patients a lot about it. I’d say, “Hey, we’re going to start this and we’re going to start that. And I want you to start a little bit slow and then work your way up because we’re trying to avoid a die-off.” And the more I talked about die-off, the more symptoms they had. As I’ve gotten more experienced over the years, really paying attention for how you talk about these things really is a benefit to the patient. It’s not that you’re avoiding the fact that treatments may have an adverse effect, but I think if you spend a whole lot of time talking about the awful things that are going to happen, sick patients are going to manifest.

DrMR:

Yes. Yes. This is just one more reason why I appreciate what we’re building at the clinic. Part of this was really an insight that you and I had recently in a back and forth, looking at the language we use when we’re giving an antimicrobial protocol. And we had some of these warnings, if you will, built into the recommendations. We revisited that and said — these tend to be rare to begin with, but are we doing more harm than good in putting this in the protocol? Could we be producing a nocebo effect? And so we’ve changed some of the language that we’re using to avoid these highly emotionally charged diagnostic terms. We’re moving away from MCAS because we think that putting a syndrome in someone’s head may not really be helpful. And also putting all these warnings for something that occurs quite rarely may also not be helpful for the individual? So, it’s a great point. And that’s why I really appreciate what we’re doing — always trying to make sure every point of communication is as refined as possible and is doing as much good in preventing as much harm as it possibly can.

DrJM:

Yeah. And I hope patients listening understand that by no means are we perfect, but one of the things we take a lot of pride in is continuously looking at our symptoms as new information comes in, as all of our experience grows, and adapting from there. Our aim is to keep getting better and better and better as we go on.

DrMR:

Yeah. It’s a constant, constant evolution. Absolutely.

DrJM:

Where do you want to go next?

4th Question: Antimicrobials & Bowel Movements

DrMR:

Alright. Let’s see. There was a follow-up question on: Do you believe improvements are being made on antimicrobials, even if bowel movements are improving? This is a good question. And it really depends on if other symptoms are improving or not. If the only complaint is constipation, then there’s a decent likelihood we may not even use antimicrobials. Perhaps part of this depends on the person’s history and some of the context, but if you’re seeing no other symptoms — no abdominal pain, no bloating, no distension, no food intolerance — and you’re just seeing constipation, then that may be purely slow transit constipation. Simply modulating someone’s diet… getting them on some magnesium… maybe having them do abdominal massage… perhaps pelvic floor work… perhaps adhesion therapy… might be the cause or the culprit. But if you’re seeing a constellation of IBS-like symptoms along with constipation, and other symptoms are improving while on the antimicrobials, but not the constipation, then yes, that means the antimicrobials are working. You continue through, get as much out of the antimicrobial therapy as you can, and then reevaluate. And if there’s still the one symptom left of constipation, that’s when you potentially pivot to some of those other therapies I just mentioned.

DrJM:

I am more and more convinced that this is a big miss in a lot of functional medicine. It is simply the importance of a cleaning out of any retained stool in a patient. It’s always so interesting to me to see a patient who comes in and they’ve had ongoing SIBO for two to three years — they’ve done rifaximin, they’ve done neomycin, they’ve done herbals, they’ve tried elemental diet, they’ve tried the low FODMAP diet. They may have signals of improvement here and there, but at the end of the day, they’re still really suffering and looking for our care. In some of those patients, when you actually tell them to go back to their GI doctor and ask for a colonoscopy prep (where you give them MiraLAX Milk of Magnesia and really clean them out, which honestly is not fun), it’s always so interesting to me to see that those patients (once the stool is eliminated) all of a sudden respond to therapies. It’s almost like the whole gut is shut down while it’s clogged. And as soon as you open it up, that’s when these patients really start moving forward. It’s one of those order of operation things that we think about in our patients. I know that’s getting away from the question, but it’s something I’ve seen twice in the last week and just worth mentioning.

DrMR:

That’s something I haven’t seen, but I’m also curious to think on that and incorporate that recommendation. I wonder if the patients I’ve seen have just self-elected to do enemas or other flushing interventions.

DrJM:

Yeah. These are a lot of the patients who are doing coffee enemas.

DrMR:

There certainly seems to be people who report benefit from enemas. I try to reconcile that series of anecdotal observations against the research literature, which doesn’t seem to support colonics, but also recognizing that the available research is not super robust.

DrJM:

It’s not targeting subsets of patients with SIBO and constipation.

DrMR:

Exactly. This is where we have to find that balance of being evidence-based, but not evidence-limited. In the recent review article that we wrote on colonics, we were not supportive, but we also left the door open for some potential benefit. And I especially think if you use therapies like colonics or flushing protocols of whatever sort to the more mid-end phase, that’s when you make sure you’re not going to gloss right over a more important causative factor — like modulating fiber or FODMAPS or using probiotics or abdominal massage. And you use that at the right time and place.

DrJM:

Totally.

Dr Ruscio Resources :

Hi, everyone. If you are in need of help, we have a number of resources for you. Healthy Gut, Healthy You – my book and your complete self-help guide to healing your gut. If you’re not a do-it- yourselfer, there is the clinic – The Ruscio Institute for Functional Medicine – and our growing clinical and supporting research team will be happy to help you. We do offer monthly support calls for our patients where I answer questions and help them along their path. Health coaching support calls every other week. We also offer health coaching independent of the clinic, for those perhaps reading the book and/or looking for guidance with diet, supplementation, et cetera. There’s also the store that has our elemental diet line, our probiotics, and other gut health and health supportive supplements. And for clinicians, there is our FFMR – Future of Functional Medicine Review database – which contains case studies from our clinic, research reviews, and practice guidelines. Visit drruscio.com/resources to learn more.

Case Study: Constipation, Eczema, and Suicidal Thoughts

DrMR:

Alright. What about a case study? Joe – I know you had a case study that you were rearing to share with people, and I’m curious to hear more about this. I love this case study. Why don’t you take us through this.

DrJM:

This is a 73 year old male that recently came through The Ruscio Institute. It was so interesting to me that I actually wrote it up in The Future of Functional Medicine Review. This is my plug for that. I’m so proud of what we’re building there. It’s just excellent clinical information. I’ll just cover what I think are the main points in this case and just refer clinicians and patients to the FFMR if they want to hear more.

DrJM:

This man came in. He’s 73 years old, and he has suffered with lifelong constipation and lifelong eczema. He’s got dry, itchy, flaky, painful skin, and it flares. It becomes unbearably itchy, hot, and burns four to five times a week.

DrJM:

Interestingly, he falls asleep after nearly every meal, and it doesn’t matter what he eats. He falls asleep five to 10 minutes after. He’s severely depressed and at the second or third visit, tells me that he’s actually been suicidal. The key things that were interesting to me were: First of all, the falling asleep after every meal is just the clearest bullet towards MCAS that I know of — completely out of control mast cell activation causing that symptom is my best assessment there. And as we dug down into this gentleman’s case, he’d had a lifelong history of these issues, but he really worsened two years ago after moving into a new home. It had become very clear that he had moved into a moldy home.

DrJM:

The single biggest thing that I did that really helped him was just convince him to move. The reason I wanted to plug this here is that treating mold is pretty complicated. It’s so easy to lose sight of telling someone to get out of their home in the midst of trying to fix the gut… and talk about lifestyle… and sequence binders… and mast cell treatment… and antifungals. But, I got him to move and he started some probiotics, but that’s about it. At a follow-up visit, he called me and he was halfway across the country, riding his motorcycle. And he and his wife were touring the country in an RV. He was just chasing her in the motorcycle.

DrMR:

That’s awesome.

DrJM:

It was just so much fun to see this guy — by no means was he 100% better — but he was not suicidal. His depression was better. His skin was better. And he was back to his vibrant lifestyle. He’s going get a lot better with time and more therapy. But man, if we had just messed around initially with talking about MCAS and binders and the vagus nerve and all the rest of it, but he just stayed in his home, I really worry that he might not have made it. Instead, he got some psychological care because he got to start feeling better, and everything fit into place when he got out of the moldy environment. That was just for me to encourage the clinicians following along that it’s very, very hard to ask someone to move, but if you have that clinical suspicion, you really need to pull the trigger and ask them to (at least) stay somewhere for two weeks to see if they feel better.

DrMR:

I was just going to say that — one of the things I’ve done in some cases was ask someone to go somewhere and get a hotel for a week or so, just to see if we can (in a prospective, controlled fashion) determine if you do feel better out of that environment. And that can be a great motivating factor for the person saying, “Wow, I really noticed I felt quite a bit better.”

DrJM:

It’s usually 24 to 72 hours and there’s a signal of improvement. It generally sustains over one to two weeks and actually gets better over about that two week period of time. What’s the cost of hiring a professional remediator and the time you wait for doing that and inspecting and doing ERMI dust tests and running air samples? A lot of times, patients can spend $2,000 minimum on just the initial assessment. Is my home moldy? Take that money and hang out at a hotel. Get some room service, man.

DrMR:

I see more and more merit in that approach because even with the assessments, there’s a gradient of how severe the findings are and it has to be weighed against how sensitive the individual is. There is definitely some gray area there. And this is why we say lab testing is really 1/4 of the decisions needed to make a decision — look at their history, their symptoms, their treatment response, and their labs all in conjunction. Maybe we should just flag for people that even an assessment for mold (something I learned personally) you don’t get a super black and white analysis back.

DrJM:

You see the really bad signals – a horribly moldy environment – but then there’s a ton of middle ground. And in that middle ground, the only thing that matters are the patient’s symptoms. If they feel better in the hotel and then worse at home, I don’t really care what their ERMI is. There’s something there in the home making them sick.

DrMR:

Right. And a good parallel would be someone could have a negative SIBO breath test, but still respond beautifully to rifaximin or to herbal antimicrobials.

DrJM:

All the time. Yep.

Episode Wrap-Up

DrMR:

Well, I think we had a good banter there, Joe. As we move to a close, anything else that’s on your mind and/or that you want to remind people of?

DrJM:

No. I think we covered quite enough for today.

DrMR:

Yeah. It was a great call and hopefully these conversations are helpful for our audience. And remember, if you are in need of help, please feel free to reach out to the clinic anytime. I know when it was just myself in the clinic, there were in some cases months of a wait to be seen, but now that we have a phenomenal and growing team, we can usually accommodate a new patient visit within just a couple weeks. As you hopefully can see, we’re putting progressively more resources into making sure that we’re not only discussing these things correctly, but are on the cutting edge of science; incorporating that science into our clinical model and making sure all of our touch points are as precise and as helpful and as cost-effective as they can be. So, I hope this was helpful and if you have questions, feel free to send them in. Otherwise, Joe and I should be back on the mic here in another couple months. Joe – Thank you so much, my friend. I’ll see you around the clinic.

DrJM:

Sounds good, man. See you soon.

DrMR:

Alright. Bye-bye.

DrJM:

Bye.

Outro:

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➕ Resources & Links

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